de la Caffinière J Y, Ferrer C, Laurent A, de la Caffinière M
Service de Chirurgie Orthopédique et Traumatologique, Hôpitaux de Saint-Denis.
Rev Chir Orthop Reparatrice Appar Mot. 1997;83(3):243-50.
Impaction in pertrochanteric fracture sites is a well known phenomenon; the screw-plate system is designed to stabilise the fracture. Although easier to use, the risk with the nail-plate system is postoperative penetration of the nail into the joint. The present study was conducted to determine the exact conditions of the impaction, and to identify possible ways to improve the nail-plate system.
MATERIAL-METHOD: The study included 129 cases of pertrochanteric fracture, excluding sub-trochanteric fractures. All fractures were fixed with a 130 degrees angulated nail-plate. In all cases, consolidation was uneventful after 8 to a 12 weeks. The anatomical type of fracture, i.e. stable or unstable, was determined according to the size of the intermediary fragment, including the trochanter minor. The displacement was measured as the difference between the length of the nail and the length of the femoral head and neck measured along the axis of the femoral neck. The parameters examined were: fracture stability degree, bony mineralisation (Singh Index), nail length, femoral neck, length nail position in the femoral head, and above all, fracture reduction. All these parameters were computerised and compared using Stat View statistics software.
Impaction was observed in 43 per cent of cases. Among these, 25 per cent were rated as slight (1 to 5 mm), 18 per cent as moderate (over 5 mm) and 9 per cent as marked (10 to 25 mm). Impaction was associated with demineralisation of the bone tissue (p = 0.001). The anatomical classification of the fracture was not a determining factor (p = 0.19), as marked displacements were also recorded in stable fractures. A posterior and inferior position of the intramedullary nail in the femoral head is one of displacement determining factors (p = 0.004, two-sided 1 test). Valgus over-correction is the most important factor, especially when it is associated with bony demineralisation (p = 0.02) and an inadequately centred intramedullary pin (p = 0.02). Shorter the femoral neck, and shorter the nail, greater was the frequency of nail articular penetration.
The risk of articular penetration therefore reaches 15 per cent in petrochanteric fractures repaired with a nail plate, set at an angle of 130 degrees. A short neck, a cervicodiaphyseal angle superior to 140 degrees, and demineralisation are the three determining parameters. Stable or unstable fracture has in fact little effect on displacement incidence, and therefore does not, on its own, warrant the use of a prosthesis in comminuted fractures. The authors compared their results to literature on progressive sliding system: the incidence of complications associated with this type of fracture treatment is identical, but the determining parameters are different.
The study shows that the nail-plate is efficient and provides simple and solid fracture fixation. However, this osteosynthesis material needs to be modified in order to improve its fixation in the femoral head.
转子周围骨折部位的嵌插是一种众所周知的现象；螺钉钢板系统旨在稳定骨折。虽然使用起来更简便，但钉板系统的风险是术后钉子穿入关节。本研究旨在确定嵌插的确切情况，并找出改进钉板系统的可能方法。
该研究纳入了129例转子周围骨折病例，不包括转子下骨折。所有骨折均用130度角的钉板固定。所有病例在8至12周后均顺利愈合。根据中间骨折块（包括小转子）的大小确定骨折的解剖类型，即稳定或不稳定。位移量通过沿股骨颈轴线测量的钉子长度与股骨头和颈长度之间的差值来测量。所检查的参数包括：骨折稳定程度、骨矿化（辛格指数）、钉子长度、股骨颈、钉子在股骨头中的位置，最重要的是骨折复位情况。所有这些参数都进行了计算机处理，并使用Stat View统计软件进行比较。
43%的病例观察到嵌插。其中，25%被评为轻度（1至5毫米），18%为中度（超过5毫米），9%为重度（10至25毫米）。嵌插与骨组织脱矿有关（p = 0.001）。骨折的解剖分类不是决定因素（p = 0.19），因为在稳定骨折中也记录到明显的移位。髓内钉在股骨头中的后下位置是移位的决定因素之一（p = 0.004，双侧1检验）。外翻过度矫正最为重要，尤其是当它与骨脱矿（p = 0.02）和髓内针未充分居中（p = 0.02）相关时。股骨颈越短，钉子越短，钉子穿入关节的频率越高。
因此，用130度角的钉板修复转子周围骨折时，关节穿入的风险达到15%。短颈、颈干角大于140度和脱矿是三个决定参数。稳定或不稳定骨折实际上对移位发生率影响很小，因此，对于粉碎性骨折，其本身并不足以成为使用假体的依据。作者将他们的结果与关于渐进滑动系统的文献进行了比较：这种骨折治疗相关并发症的发生率相同，但决定参数不同。
该研究表明钉板有效，能提供简单而牢固的骨折固定。然而，这种骨合成材料需要改进，以提高其在股骨头中的固定效果。
